PCS EMERGENCY PERMISSION FORM

(To be completed and signed by parent/guardian)

STUDENT______________________________GRADE__________AGE____________

Please list any significant health problems that might be significant to a physician evaluating your child in case
of an emergency.

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

Please list any allergies to medication, etc.

_____________________________________________________________________________
_____________________________________________________________________________

Is student presently taking medication? __________

If so, what type?____________________________________________________________________________

Does the student wear contact lenses? __________

Please list date of last tetanus shot. ______________

EMERGENCY AUTHORIZATION:
In the event of an emergency, I hereby give permission to the physicians selected by the coaches and staff of
PCS to hospitalize, secure proper treatment for, and to order injection and/or anesthesia and/or surgery for the
person named above.

Parent/Guardian Signature: ______________________________________Date ____________________

Relationship to student: _________________________________________________________________

Daytime phone number where you may be reached in an emergency (include area code).

Mother - Work: _________________________________ Cell: __________________________________

Father - Work: _________________________________ Cell: __________________________________

Evening time phone number where you may be reached in an emergency (include area code).

Home: ____________________________________

EMERGENCY PERMISSION FORM MAY BE REPRODUCED

TO TRAVEL WITH RESPECTIVE TEAMS AND IS ACCEPTABLE
FOR EMERGENCY TREATMENT IF NEEDED